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Ohio Mental Health & Addiction Services Twin Valley Behavioral Healthcare

2200 West Broad Street Columbus, Ohio 43223 Invitation to Bid

Medical Equipment Preventive Maintenance and Compliance Testing

Invitation to Bid Number: MHA14133

Invitation to Bid Issued: July 29, 2013

Invitation to Bid Due: August 12, 2013 by 2:00 PM

A. Project Overview Twin Valley Behavioral Healthcare is accepting bids for Medical Equipment, preventive maintenance and Electrical Safety, inspection and testing at 2200 West Broad Street, Columbus Ohio

Scope of Work

• Anticipated Contract periods: FY14 – August 1, 2013 – June 30, 2014 and FY15 - July 1, 2014

– June 30, 2015. • Electrical safety inspection and testing per NEC and NFPA standards to be completed for all

equipment listed in Exhibit A1. Reporting of inspection and testing to be in compliance with current Joint Commission Standards. The report of inspection procedures, testing results, deficiencies and recommendations for each piece of equipment to be submitted at completion of work.

• Biomedical Equipment: preventive maintenance (per manufacturer recommendations) and inspections shall be performed on equipment listed in Attachment A at the frequency indicated. Reporting of inspection and testing to be in compliance with current Joint Commission Standards. The report of inspection procedures, testing results, deficiencies and recommendations for each piece of equipment to be submitted at completion of work.

• Equipment Inventory and Control File: computer control records shall be created for each piece of equipment designated in Exhibit A. Owner approved unique control number tag to be permanently affixed to the device and available through reporting system including description of the device, manufacturer’s name, model number, serial number, testing protocol, and type of service completed by the Vendor. The file will outline the both the maintenance schedule and the results of the preventive maintenance work. A computer disk in owner acceptable format to be updated and submitted to TVBH after each inspection.

• The selected Vendor will be notified in writing a minimum of 10 days prior to the anticipated start date of semi- annual and annual onsite services.

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• Vendor shall provide labor, equipment and materials to complete this work. • Vendor shall advise the Clinic Director of any necessary repairs. Parts and labor to make any

necessary repairs shall be handled as an additional cost. A written quote for additional work shall be provided, and a purchase order will be assigned before work commences.

• Vendor shall submit a list of equipment deficiencies or recommended repairs at completion of preventive maintenance.

• All work shall be scheduled through the Clinic Department and be performed Monday through Friday (7:30 am to 5:00 pm)

• Pre-bid walkthrough is scheduled for July 31, 2013 at 9:00 a.m. To be held in the KOSAR Building, Clinic Department, 2200 West Broad Street, Columbus Ohio.

B. Vendor Requirements • Vendor shall use trained personnel directly employed or supervised by Vendor’s

Company. • The purposed site supervisor shall have a minimum of three (3) years’ experience in

medical equipment maintenance and repair for types listed in Exhibit A. • Current license in compliance of NFPA and NEC for testing and maintaining electrical

equipment. • The Vendor shall provide telephone and cell phone or pager numbers of proposed

Supervisor and Company Principle, so that, TVBH may contact Vendor during the course of this project.

• Maintaining Records/Reporting: The Vendor shall maintain a complete set of records of each scheduled preventive maintenance inspection including, but not limited to inspection dates, items checked, repairs, maintenance performed, problems noted and a statement of accounts with the following information: Scheduled inspection charge for the current period and the accumulated total to date; and repair charges for the current period and the accumulated total to date.

• Following completion of each scheduled inspection or repair, the Vendor shall review with the facility contact person (or designee) the details of the work just completed and any recommendations for necessary repairs or improvements to the system. Within one (1) week following a scheduled inspection or repair, the contractor shall file a written report that lists all repair needs and deficiencies, that provides a copy of the inspection log that covers the information specified. The list of technicians shall be included in the report with and certification or licenses listed.

• Refer to “General Services Agreement” (attached) for requirements prior to executing the Agreement.

C. Bid Requirements

• All information requested shall be provided as specified. Failure to comply

will void the bid. • Vendors shall include submit their bid as follows:

1. Vendor business or corporate letterhead paper including, federal tax ID Number, contact person, phone number, and signature

2. Item No 1: Bid to indicate FY14 – Lump Sum costs as described in Scope of Work

3. Item No. 2: Bid to indicate FY15 – Lump Sum costs as described in Scope of Work

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4. Hourly Rate (Certified Technician) for repair and maintenance which is not covered by the agreement

• Request to change or alter an original bid must be received in writing, prior to the submittal deadline.

D. Specification Requirements

• A purchase order will be issued for the FY14 fiscal year with option of renewal for FY15;

payment will be based on percent of the work complete. • Any repair or maintenance work beyond the scope of work will require the Vendor to obtain

proper authorization prior to completing the work. • Exhibit A • Comply with TVBH “Contract Procedures” (attached) • Comply with TVBH “Protected Information Agreement” (attached)

E. Evaluation of Proposals and Award of Contract Proposals will be scored and point values given to the following criteria.

Technical Criterion Weight Rating ( 0 – 5 ) Technical Score

References 25 Technician Experience 25 Lump Sum Rate 25 Hourly Rate 25 Total Weight 100

F. Submission of Proposal

Electronic bids must be sent to DMHBidOpportunity@mh.ohio.gov. Original bid may be sent via U.S.mail to: Mandy Smith, Twin Valley Behavioral Healthcare, KOSAR Clinic, 2200 West Broad Street, Columbus, Ohio 43223. The bid number MHA14133 must be clearly marked on the sealed envelope and submitted on company letterhead before 2:00 PM on August 12, 2013. Bids must include: vendor name, address, Federal Tax Identification number, contact person, phone number, signature, total cost, all elements specified under Bid Requirements, and documentation identifying experience relevant to proposals. Questions regarding the Request for Proposal must be sent via the State of Ohio Procurement Website www.ohio.gov under the Request for Proposal submit inquiry.

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OBM-5657 05/02/2011

VENDOR INFORMATION FORM

All parts of the form must be completed by the vendor and returned to Ohio Shared Services. The information must be legible.

SECTION 1 – PLEASE SPECIFY TYPE OF ACTION

NEW (W-9 OR W-8ECI FORM ATTACHED) CHANGE OF CONTACT PERSON/INFORMATON

ADDITIONAL ADDRESS (PLEASE PROVIDE COPY OF INVOICE OR LETTER OF EXPLANATION)

CHANGE OF ADDRESS – ENTER OLD ADDRESS

CHANGE OF TIN (NEW W-9 AND LETTER OF EXPLANATION OF CHANGE, WHICH INCLUDES OLD TIN, IS REQUIRED)

CHANGE OF NAME (NEW W-9 AND LETTER OF EXPLANATION OF CHANGE IS REQUIRED)

CHANGE OF PAY TERMS CHANGE OF PO DISPATCH METHOD OTHER_____________________________________

SECTION 2 – PLEASE PROVIDE VENDOR INFORMATION

LEGAL BUSINESS OR INDIVIDUAL NAME: (MUST MATCH W-9 OR W-8ECI FORM)

BUSINESS NAME, TRADE NAME, DOING BUSINESS AS: (IF DIFFERENT THAN ABOVE)

FEDERAL TAX ID (TIN), EMPLOYER ID (EIN) OR SOCIAL SECURITY NUMBER (REQUIRED):

BUSINESS ENTITY: (IF A SOLE PROPRIETOR, THE INDIVIDUAL’S NAME MUST APPEAR IN LEGAL BUSINESS NAME) CHECK ONE:

INDIVIDUAL/SOLE PROPRIETOR CORPORATION S CORPORATION PARTNERSHIP TRUST/ESTATE

LIMITED LIABILITY COMPANY CIRCLE THE TAX CLASSIFICATION (C=CORPORATION, S= S CORPORATION, P=PARTNERSHIP) ______________

OTHER (PLEASE EXPLAIN)

SECTION 3 – PLEASE PROVIDE COMPLETE ADDRESS 1 (IF MORE THAN 2 ADDRESSES, INCLUDE A SEPARATE SHEET)

ADDRESS: COUNTY:

CITY: STATE: ZIP CODE:

SECTION 4 – PLEASE PROVIDE COMPLETE ADDRESS 2

ADDRESS: COUNTY:

CITY: STATE: ZIP CODE:

OBM-5657 REV. 02/15/2011

SECTION 5 – CONTACT INFORMATION AND PERSON TO RECEIVE PURCHASE ORDER

NAME:

WEBSITE:

PHONE: FAX:

E-MAIL:

SECTION 6 - STRATEGIC SOURCING CONTACT INFO (PERSON TO RECEIVE E-MAIL NOTICE OF BID EVENTS)

THE USER ID & PASSWORD TO COMPLETE STRATEGIC SOURCING REGISTRATION WILL BE SENT TO E-MAIL ADDRESS BELOW.

NAME::

E-MAIL: PHONE NUMBER:

SECTION 7 – IS YOUR BUSINESS CURRENTY CERTIFIED AS? (PLEASE CHECK)

MBE (MINORITY BUSINESS ENTERPRISE) EDGE (ENCOURAGING DIVERSITY, GROWTH, & EQUITY) N/A

SECTION 8 – PAYMENT TERMS (PLEASE CHECK ONE, OTHERWISE NET 30 WILL BE APPLIED BY DEFAULT)

2/10 NET 30 NET 30 NET 45 NET 60 NET 90

SECTION 9 – PURCHASE ORDER DISTRIBUTION-OTHER THAN USPS MAIL (NOTE: APPLICABLE FOR VENDORS THATRECEIVE PO ONLY (INPUT E-MAIL ADDRESS OR FAX NUMBER BELOW)

E-MAIL OR FAX:

SECTION 10 – PLEASE SIGN AND DATE

PRINT NAME:

SIGNATURE:

DATE:

SECTION 11 – STATE OF OHIO AGENCY CONTACT INFORMATION (AGENCY WHERE GOODS OR SERVICES ARE DELIVERED)

AGENCY NAME: OHIO DEPARTMENT OF MENTAL HEALTH

E-MAIL: Lucille.Fuller@mh.ohio.gov PHONE NUMBER: 614-466-7697

COMMENTS:

Note: This document does contain sensitive information. Sending via non-secure channels, including e-mail and fax can be a potential security risk.

SUBMIT FORM TO:

Mail: Ohio Shared Services P.O. Box 182880 Cols., OH 43218-2880

Fax: (614) 485-1052 E-mail: vendor@ohio.gov

QUESTIONS? PLEASE CONTACT:

Phone: 1 (877) OHIO-SS1 (1-877-644-6771) 1 (614) 338-4781 E-mail: vendor@ohio.gov

Form W-9(Rev. January 2011)Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give Form to the

requester. Do not

send to the IRS.

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Name (as shown on your income tax return)

Business name/disregarded entity name, if different from above

Check appropriate box for federal tax

classification (required): Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)

Other (see instructions)

Exempt payee

Address (number, street, and apt. or suite no.)

City, state, and ZIP code

Requester’s name and address (optional)

List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on the “Name” line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.

Social security number

– –

–

Employer identification number

Part II Certification

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

3. I am a U.S. citizen or other U.S. person (defined below).

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4.

Sign Here

Signature of

U.S. person Date

General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Purpose of FormA person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA.

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to:

1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners’ share of effectively connected income.

Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are

considered a U.S. person if you are:

• An individual who is a U.S. citizen or U.S. resident alien,

• A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States,

• An estate (other than a foreign estate), or

• A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners’ share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income.

Cat. No. 10231X Form W-9 (Rev. 1-2011)